Form 2: Application for project information memorandum
and/or building consent
Section 33 or 45, Building Act 2004
1. THE BUILDING [Complete all applicable sections]
2. APPLICATION [Nominate as applicable]
3. THE PROJECT
Central Otago District Council
Clutha District Council
Dunedin City Council
Gore District Council
Invercargill City Council
Mackenzie District Council
Queenstown Lakes District Council
Southland District Council
Timaru District Council
Waimate District Council
Waitaki District Council
OFFICE USE ONLY:
Consent Number:
…………………………………
PIM Number:
…………………………………
Compliance Schedule No:
………………………………….
Date received:
………………………………….
Street address of building: ………………………………………………………….…..…………….……..….…..
…..………………………………………………………………………………………….
[If no street address details of nearest intersection] ………………………….……………….……………………….…………
Legal description of land where building is located: Lot ………………………. DP………………...………….
Site area ……………… (m
2
) Sec ………………………. Block……………...…………
Building name: ……….…………………….……… Valuation Number ………………………….……………….
Location of building within site/block number: [Include nearest street access] …………………………….………………
………………………………………………………………………………………………………………………………
Number of levels: [Above & below ground] ………………..………..….. Level /Unit Number: …………..……………
Floor area: …………………..…..… (m
2
) [Indicate area affected by the building work]
Current, lawfully established, use: …………………………………… Year First Constructed: ………………
[Add no. of occupants per level and per use if more than 1] ……………………………………………..………………………………………
………………………………………………………………………………………………………………………………
Year first constructed: [Approximate date is acceptable e. g.: c1920s or 1960-1970] ……………………………………
I request that you issue a: (for the building work described in this application)
Project Information Memorandum (PIM)
Project Information Memorandum (PIM) and Building Consent (BC)
Building Consent The existing PIM No [If applicable] is: …..………..……………….
Amendment to an existing Building Consent. The existing BC No is: ………………….……..
Staged Consent Being stage ……….. of ……….. stages
State the reference number if this application involves a National Multiple Use Approval: ……………………………………….…………
Name: …………………….………………….……Signature: ……………..…………………………Date: ………….…..……
The signature is that of the Owner OR the Agent on behalf of and with the approval of the Owner
This is my address for service and I acknowledge that some communications may be by email.
Please nominate if email address is not available
DESCRIPTION OF BUILDING WORK: (Provide sufficient information below to enable scope of work to be fully understood)
…………………………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………………………
……….…………………….……………………….……………………….………..…………….…………………….……………………………………………
Current use of building: ............................................................................................................ [E.g. Home, implement shed, office]
Will the building work result in a change of use of the building? Yes No. If Yes, provide details of the new use of the building:
…………………………………………………………………………………..........………………………………………………………………………………
Intended life of the building if less than 50 years: ……………… [Years]
List Building Consents previously issued for this project (if any): ………………………………………………………………………………………………...……
Estimated value of the building work on which the building levy will be calculated (including goods and services tax):
$................................................................ [State estimated value as defined in section 7 of the Building Act 2004]
Is prescribed energy work to be part of this Building Consent (tick if applicable) Gas Electricity
SBCG FORM 2
Version - 1 November 2019 Page 1 of 4
click to sign
signature
click to edit
4. OWNER 5. AGENT [Only required If application is being made on behalf of the owner]
5. THE BUILDING [If item is not applicable put NA in the space]
6. RESTRICTED BUILDING WORK
7. PROJECT INFORMATION MEMORANDUM [Do not fill in this section if the application is for a building consent only]
Name of Owner: …………..............…………...………...................
Contact person ……………….………………….…….…..…………….
Mailing address: …….…………………………………..……………
……………………………………..……………………..……..…..……..
Street address/registered office: ……………………………………….
……….………..…………………………………………..…….…………
Phone No.: Landline: ………………………….……………….…….
Mobile: …………………………….………..….………
Daytime: ……………………….…………...………
After hours: ………………….……………...………
Facsimile: ………………………………..………….……
Email: ……………………………………………………………………...
Website: ………………………………………………………..….………
THE FOLLOWING EVIDENCE OF OWNERSHIP IS ATTACHED:
Certificate of Title Lease Agreement
Agreement for Sale and Purchase Other document
FIRST POINT OF CONTACT for communications with the Council / Building Consent Authority: Owner Agent
Or : (If different to above details) Name :………………………………………………….. Email:…………………………………………………..
Mailing Address:……………………………………………………… Phone: …………………..……. Facsimile:……………………….
…………………………………………..…………
BILLING (PAYER) DETAILS: Owner Agent Other, (state name & mailing address) ……………………………………………………...
……………………………………………………………………………………………………
The following matters are involved in the project: [Nominate the matters relevant to the project]
Subdivision
Alterations to land contours [e.g. digging out the site for a building platform]
New or altered connections to public utilities [e.g. Council sewer, storm water or water mains]
New or altered locations and/or external dimensions of buildings
New or altered access for vehicles
Building work over or adjacent to any road or public place
Disposal of stormwater and wastewater
Building work over any existing drains or sewers or in close proximity to wells or water mains
Other matters known to the applicant that may require authorisations from the Territorial Authority: [Specify]
………………………………………………………………………………………………………………………………………………..……….…..…
SBCG FORM 2
Version - 1 November 2019 Page 2 of 4
Will the building work include any restricted building work? Yes No
If Yes, provide the following details of all licensed building practitioners who will be involved in carrying out or supervising the restricted building
work (If these details are un-known at the time of the application, they must be supplied before the building work begins.):
Name
Licensing Class
Licensed Building Practitioner Number
(or registration number if treated as being licensed under
section 291 of the Building Act 2004)
Note: Continue on another page if necessary
8. BUILDING CONSENT
THE BUILDING WORK WILL COMPLY WITH THE BUILDING CODE AS FOLLOWS:
NZS 4121 Alternative Solution Waiver/Modification
Accessible
Design
Method
Please complete
Form SBCG 34.1
Please complete
Form SBCG 23.1
B1
Structure
B1/AS1 B1/AS3 B1/VM1
B1/VM4
B2
Durability
B2/AS1 B2/VM1
C1-6
Protection from fire
C/AS1 C/AS2 C/VM1
C/VM2
D1
Access routes
D1/AS1 D1/VM1
D2
Mechanical installation for
D2/AS1
□ □
D2/AS2
access
D2/AS3
E1
Surface water
E1/AS1 E1/VM1
E2
External moisture
E2/AS1 E2/AS2 E2/VM1
E2/AS3
E3
Internal moisture
E3/AS1
F1
Hazardous agents on site
F1/VM1
F2
Hazardous building materials
F2/AS1
F3
Hazardous substances and
processes
F3/VM1
F4
Safety from falling
F4/AS1
F5
Construction and demolition
hazards
F5/AS1
F6
Visibility in escape routes
F6/AS1
F7
Warning systems
F7/AS1
F8
Signs
F8/AS1
F9
Restricting access to
residential pools
F9/AS1 F9/AS2
G1
Personal hygiene
G1/AS1
G2
Laundering
G2/AS1
G3
Food preparation and
prevention of contamination
G3/AS1
G4
Ventilation
G4/AS1 G4/VM1
G5
Interior environment
G5/AS1
G6
Airborne impact sound
G6/AS1 G6/VM1
G7
Natural light
G7/AS1 G7/VM1
G8
Artificial light
G8/AS1 G8/VM1
G9
Electricity
G9/AS1 G9/VM1
G10
Piped services
G10/AS1 G10/VM1
G11
Gas as an energy source
G11/AS1
G12
Water supplies
G12/AS1
G12/AS2
G12/VM1
G13
Foul water
G13/AS1
G13/AS2 G13/VM1
G13/AS3
G13/VM4
G14
Industrial liquid waste
G14/AS1 G14/VM1
G15
Solid waste
G15/AS1
H1
Energy efficiency
H1/AS1 H1/VM1
B1-H1
Simple House Solution
SH/AS1
B1-H1
Back Country Hut
BCH/AS1
Acceptable Solution
Nominate relevant clauses
Means of Compliance
Nominate relevant compliance path(s) for each clause selected.
Verification
Building Code Clause
The following plans and specifications are attached to this application: (please enter these in section 10 over page)
SBCG FORM 2
Version - 1 November 2019
Page 3 of 4
9. COMPLIANCE SCHEDULE (specified systems are defined in regulations)
The specified systems for the building are as follows:
The following specified systems are being altered, added to,
or removed in the course of the building work:
or
There are no specified systems in the building.
10. ATTACHMENTS
11. CONTACTS (involved in this project)
The following documents are attached to this application (All plans and specifications must meet the minimum requirements set out in the
regulations or required by the building consent authority):
[Nominate as applicable]
Plans and specifications (list) (or attach a list)………………………………………………………………………………………………………….
……………………………………………………………………………………………………………………………………………………………………..
Memoranda from licensed building practitioner(s) who carried out or supervised any design work that is restricted building work
Project Information Memorandum Development contribution notice Certificate attached to Project Information Memorandum
Other information relevant to this application: [Please specify]: …………………………………………..…………………………..…………..
……………………………………………………………………………………………………………………………………………………….
Current Certificate of title provided
Please provide the details required by completing either form:
SBCG27 Compliance Schedule Specified Systems (or)
SBCG11 Application for amendment to Compliance Schedule
SBCG FORM 2
Version - 1 November 2019 Page 4 of 4
Designer
Name(s): ............................................................................................
Postal Address: .................................................................................
...........................................................................................................
Mobile: ........................................... Daytime: ...................................
Reg No: ............................ Email: ....................................................
Engineer
Name(s): ...........................................................................................
Postal Address: ................................................................................
..........................................................................................................
Mobile: ........................................... Daytime: ..................................
Reg No: ............................ Email: ...................................................
Builder
Name(s): ............................................................................................
Postal Address: .................................................................................
...........................................................................................................
Mobile: ........................................... Daytime: ...................................
Reg No: ............................ Email: ....................................................
Gasfitter
Name(s): ...........................................................................................
Postal Address: ................................................................................
..........................................................................................................
Mobile: ........................................... Daytime: ..................................
Reg No: ............................ Email: ...................................................
Drainlayer
Name(s): ............................................................................................
Postal Address: .................................................................................
...........................................................................................................
Mobile: ........................................... Daytime: ...................................
Reg No: ............................ Email: ....................................................
Plumber
Name(s): ...........................................................................................
Postal Address: ................................................................................
..........................................................................................................
Mobile: ........................................... Daytime: ..................................
Reg No: ............................ Email: ...................................................
Electrician
Name(s): ............................................................................................
Postal Address: .................................................................................
...........................................................................................................
Mobile: ........................................... Daytime: ...................................
Reg No: ............................ Email: ....................................................
Other
Name(s): ...........................................................................................
Postal Address: ................................................................................
..........................................................................................................
Mobile: ........................................... Daytime: ..................................
Reg No: ............................ Email: ...................................................
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